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WE HAVE WAITED TOO LONG
For Incremental Reform To Bring Us UHC
In 1973 I.S. Falk published a history of health care reform in the U.S. beginning with the work of the "Committee on the Costs of Medical Care" or CCMC.
The CCMC published its first recommendations about strategies to achieve medical security for the American
people in 1932. See: Milbank Memorial Fund Quarterly, "Health and Society" Volume 51 Number 1 Winter of 1973.
After a few comments on Dr. Falk's history we present the commentary by Jeoff
Gordon published with that article in 1973.
In 1934 President Roosevelt was exploring how to secure medical care along with the other necessities of life under emergency conditions, but with pressure from the AMA wound up with the Social Security Act of 1935 (along with some benefits for crippled children and maternal/child health programs). Falk explains how during the next forty years of give and take, coverage of the American people has continued to fall short and proposed legislation to overhaul the system fundamentally has been defeated by powerful interests.
Dr. Falk concluded his 30 page history with this thought:
In the contending that is ahead within and between the legislative and the executive branchesof our government, the medical care program involves large and influential political stakes. Surely we should be able to join in supporting what is based on promising guidelines for one nationalsystem of medical care for everyone, and in resisting further commercialization and fractionation of medical care and reliance on the same leadership and the same mechanisms that have brought us to the current crisis.
Dr. Falks article was followed by a seven page commentary by Jeoff Gordon. Dr. Gordon's commentary strongly argues that 40 years of attempted change towards covering everyone through incremental reforms should be enough to convince anyone of the futility. Of course, we know that now after 70 years we are still confronted with supposed "Universal Health Care Activists" who claim that incremental reform will bring us UHC!! Dr. Gordon's 1973 commentary rings amazingly poignant today. It follows in its entirety.
1973 COMMENTARY BY JEOFFRY B. GORDON
In the last 100 years, the use of scientific techniques to promote health has created a virtual revolution in mans destiny. Medical science, both in personal health care and in environmental modification, has made quantum leaps in improving the life situation and life expectancy of much of the world's population. However, the issues of medical care, the issues of the organization of personal health services, especially in this country, are still tied up in knots by conflicting philosophies, contesting politics, and gaps in knowledge and technique. The inspiration for Professor Falk's review of the evolution of medical care policy and legislation in the United States as he has personally known it, comes not only at the time of a significant anniversary, but also out of a sense of frustration, and even dismay, at our nation's continuing hesitancy- and, perhaps, unwillingness-to cope definitively with its medical care problems.
The past decade has produced even more than the usual glimmers of hope: massive federally supported financing programs, health planning agencies, neighborhood health centers, the "new breeds of health activists" (Falk, 1972)-both radical critics and innovators and more conservative management types, as well as often spirited public discussion complete with Presidential messages. Yet, still the goal remains in the foggy distance. Not only has a public consensus failed to coalesce, but, as in the past, many of the piecemeal attempts at solution have been seen to be "Pyrrhic victories (Falk, 1973) ." Furthermore, that group of people whose interest, discipline, and vocation it is to be concerned with medical care issues and who have a great potential responsibility to assist in the creation of public policy have themselves yet to develop a cogent analysis. Administrative, clinical, and political considerations are needed to fashion a coherent and forceful positive strategy for establishing health care as a government guaranteed right.
Professor Falk was asked to review his long, intimate experience in this arena, to evaluate it, and to abstract from it lessons which would be useful to those who will be carrying on the struggle. Not only has he done an admirable job in reviewing history and drawing lessons from it, but also, in my opinion, his observations and inferences are significant and forceful because of the experience upon which they are based and their completeness in suggesting future actions. In addition, as is seen from the points I emphasize, they are quite radical in their implications, professor Falk's advice must be considered seriously by all of us who are involved in medical care issues.
The first lesson that this review demonstrates to us is, however, a much more conservative one; i.e., the value of having an historical perspective. This is a special message to the "new breed of activists" who, for all their enthusiasm and rhetoric, have a major shortcoming in their general rejection of the past, discarding its lessons along with its failures. Professor Falk first teaches us some humility: the vision of the Committee on the Costs of Medical Care is more than "still pertinent today" (1973), it is embarrassingly comprehensive and difficult to improve upon, as the following verbatim statement of their ultimate objective in the organization of medicine reveals (Committee on the Costs of Medical Care, 1970: 59-68):
The keystone is the development of one or more nonprofit "community medical centers" in nearly every city of approximately 15,000 population or more.
This center would include a well-equipped general hospital, an out-patient department, and a pharmacy. It would provide offices for physicians, dentists, technicians, and subsidiary personnel, and headquarters for nurses. All facilities necessary for . complete medical service . . . [as well as] home nursing, . housekeeper service, . medical social service . . would be supplied and an ambulance service maintained. Preventive medicine would receive special emphasis. Full use would be made of periodic medical examinations .
In each center a special board, similar to the boards of voluntary hospitals but more widely representative of the community, would direct the general policies and assume responsibility for the finances. . . . Inter-center competition would be minimized through . coordinating boards. . All or nearly all (practitioners) . . . of the areas served would eventually be on the staff. . . . The personnel of the center would be remunerated on a salary basis, on a capitation or fee basis, or by a proportional division of receipts. . . Within the medical center, the role of the family practitioner would be prominent and respected, . . among the best paid.. on the staff.
Cost could be met in one of three ways:
(1) by Insurance paid for in full by the individuals or families served, with or without assistance from their employers,
(2) by the use of tax funds, or
(3) by a combination of insurance and taxation....
The third method is ultimately the most desirable. Under this plan an average weekly or monthly amount would be ascertained which individuals or families, including even domestic servants and casual laborers, could pay without undue hardship. The balance would be paid by the local government . assisted where necessary by the state or Federal government.
That was written under Falk's guidance forty years ago and it is easy to see that, for all our sophistication and study, we have not been able to improve upon this ideal scheme, nor have we made much progress in making it a national reality.
Professor Falk's historical approach also emphasizes the importance of analyzing the barriers to success and of developing appropriate strategies. All too often the reformist liberal in human services either naively shies away from competing appropriately in the public policy arena or enthusiastically joins battle without a well-prepared strategy-leaving "acrimonious . . condemnation . . . by professional leadership," "fears and timidities at high political levels," and "specifications . . taken mainly from the opponents" (Falk, 1972) to carry the day. How many of the "new activists" are aware that their formula for success was articulated so completely, with so much authority, so long ago? How many of us are aware of the struggles our predecessors fought, and sometimes won, in the past? Who among us in the younger generation have studied the opposition and the battle plan in such struggles as those around the Kaiser Foundation Medical Care Program in the Western states in the 1940s, the Group Health of Puget Sound in the 1950s, the United Mine Workers' hospitals and group practices in Appalachia in the 1950s, President Truman's push for a national health program in the late I 940s, or Denver's development of a community health network more recently? Professor Falk is here reemphasizing a point he made in the 1971 Michael M. Davis Lecture (page 1):
We are in trouble with respect to medical care not so much because we have failed to recognize existing needs or to anticipate prospective inadequacies, but more because we have lacked the courage and determination to take needed action over the resistances of those who were content with current practices or who feared change.
Let us look then at the content of Professor Falk's review. From his long experience, he has distilled a very clearly articulated conception of what the goals and standards of a workable, yet ideal health care system are. The pragmatic details of this national medical care system have been laid out in exquisite detail and have been incorporated into the proposals of the Committee for National Health Insurance (CNHI) which has benefited from the leadership of Professor Falk as Chairman of its Technical Subcommittee. The resulting legislative proposal remains unique as the most comprehensive and progressive proposal alive in the public arena today, and Professor Falk has here outlined its principles clearly for us. The significance of some of the assumptions underlying this proposal should not be lost, for they are quite radical and demand major social change. They are all the more impressive because they are not based on ideological or philosophical abstractions, but on Falk's forty years of practical experience.
Professor Falk (1973) strongly urges us to "release Aesculapius from the marketplace." His critical review of the effects of the insurance company mentality on guaranteeing a human right and of the "fiscal sovereignties" of medical providers seriously questions the capacity of the competitive market and the profit motive to provide responsive and needed medical care. His long familiarity with the "leadership of America's 'organized medicine' [and its commitment] to the continuing professional domination and control of the system . . blind to the needs for better design of organization and for more adequate methods of payment" (1973) strikes hard at what has historically been an unchallenged elitist system which must now be remade into a public utility.
His jaundiced view of categorical disease and limited beneficiary programs, especially the inherently discriminating and second-class welfare medical programs, calls loudly for universal entitlement to health care as a basic right for all. His cynicism about making further "openminded, extensive and time-consuming studies of medical care in the national scene" (1972) pinpoints the diversionary nature of many contemporary health planning efforts. The implication of these assumptions is radical, for their impact is clear: provision of adequate health care for all Americans must be based on major changes in our attitudes and behavior toward each other, as well as changes in our public policy and legislation.
Moreover, Professor Falk does not stop at a mere statement of the goals and means to achieve a national health care system (no small accomplishment by itself), but he goes further to recommend to us a strategy which could result in gaining the desired ends (1972):
We should not repeat the mistakes of the past and again achieve only compromises that nullify good intentions . . compromises that will be designed as much to preserve the vested interests of those who exploit medicine and medical care as to serve the general welfare Avoid such compromises even if at the price of further delay in enactment of needed provisions.
This is impressive counsel coming from a man who has forty years of not wholly unsuccessful pragmatic compromise under his belt. Informal conversation with Professor Falk finds him standing fast in this altogether radical strategy, believing that the accomplishments of the past forty years, as successful as they have been, have served to patch an inadequate system, deferring its collapse, while preventing any major renovation. If the health advocates had stood firm-even delaying needed provisions-then perhaps sometime during the past forty years the stresses of the malfunctioning system would have created the need, atmosphere, and motivation for a major overhaul. Even now, Professor Falk believes, the situation is unchanged-compromises must be avoided to create the potential for major change. In fact, Professor Falk says, we should be organizing avidly to support the positive legislation offered by the CNHI and to defeat opposing or even half-way measures.
This clarion call of surprising firmness and commitment is more likely to awaken the skeptical radical than the pragmatic politicians and administrators who must bargain and compromise in the flow of their daily activities. It must be remembered that it is the advice of one of the foremost of the latter. In addition, the magnitude of the problem and the frustration leads Professor Falk (1973) to call for unity among health advocates of all persuasions so that the issue can be resolved: I would urge . . . [the disaffected to] sacrifice so much of their independence of action as is the price of joining in support of the most promising proposal. I can see no hope for substantial progress in the near-time future on any other course. Support need not be uncritical; but neither can it be altogether helpful if uncompromising
The call for solidarity is often made, but its accomplishment is rare. However, Professor Falk's arguments are persuasive and, in any case, the CNHI proposal is literally the only rallying point in existence. I wonder-and even hope-that it just might be possible to follow this battle plan. Professor Falk's analysis is idealistic, yet practical, encompassing all the elements of a successful approach, and his suggestions are truly radical -suggesting a strategy, unity of purpose and commitment as well as a magnitude of change not often expressed in American public interest groups.
I hope that Professor Falk's paper and this discussion illuminate the issues and their rationale so that the many people involved in medical care issues can come together to resolve properly this problem. I fear, though, that we will continue to muddle through, merely to repeat the past and compromise away our opportunities in the name of pragmatism. I doubt this will resolve anything, for Professor Falk and I agree that the supporters of the status quo are strongly motivated in their coherent protective strategy.
Here I must express my concern with a critical issue that Professor Falk does not deal with. How can the goal of good health care be attained without public support and involvement? The history presented by Professor Falk does not show a strategy designed for mass political action. The groups he has worked with were never really able to make health care a popular public issue (except perhaps in the period 1960 to 1965 when the American Medical Association, in opposition, did it for them). It is a well-recognized phenomenon in the United States that the patient role is defined by individual isolation, impotence, lack of responsibility and dependency; further, that the health role is characterized by denial and avoidance of unpleasant circumstances, including illness. Thus, unlike education, medical care has no large and constant constituency (other than health workers themselves). Yet, everyone is affected.
I would suggest that a significant reason for the lack of success over the last 40 years has been in a failure to mobilize the public's strong concerns about health care so as to generate the full political support required for success. This remains to be done and remains essential to success. I believe there is a developing crisis in human services. They are superficial, elitist, sterile, too often unresponsive. These constitute problems which cannot be overcome through technology and management methods alone. I submit that the only successful reform of the medical care system is the one based on local governance by an involved, concerned and sophisticated consuming public.
Perhaps Professor Falk would disagree on the need to bring the public in. But I contend that this is not more radical than the issues he has raised and is essential to the triumph of his goals. Since we have finally agreed that we must push for success, we ought to go the whole distance.
References
Committee on the Costs of Medical Care 1970 Medical Care for the American People. Washington, D.C.: U.S. Department of Health, Education and Welfare.
Falk, I. S. 1971 National Values and Programs for the Financing of Medical Care. Chicago: Center for Health Administration Studies, University of Chicago.
1972 Medical Care in the USA: 1932-1972 . . . : Problems, Proposals and Programs from the Committee on the Costs of Medical Care to the Committee for National Health Insurance. Paper presented at the Annual Meeting of the American Public Health Association, Atlantic City, New Jersey.
1973 Medical Care in the USA: 1932-1972 . . Problems, Proposals and Programs from the Committee on the Costs of Medical Care to the Committee for National Health insurance. Milbank Memorial Fund Quarterly/Health and Society 51 (Winter) 1-31
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